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PLUMBING-INSPECTOR RECORD
<br />COMMENTSDATEAPPBOVALS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildi Sewer
<br />Area/Storm Drain
<br />r/ Clarifierlnterce
<br />TOP OUT
<br />Waste & Vent
<br />Water Pi n
<br />Roof Drain
<br />Tub/Shower Test
<br />POOL/SPA
<br />P-tr Drain Line
<br />Main Drain/Pool Pi i
<br />Fill Linei Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn S inkler
<br />5 8anilSewe
<br />Ba CE
<br />Rou h Plumbin
<br />Final Gas Test
<br />Meter Release
<br />s/bFINAL
<br />Notes Remarks Etc.
<br />()\lNtiR Iltrll,l)t,ilt l)1.:1,( ,\R,\ I loN
<br />I hcrchy afiirm und.r pcnrlryolFljury rhrr I nm crcnrol fmm rhc c(n rrntrr l,i.cn{ Lrs r'or lhc toll'sin8 rc{sn (sc'7o:ll5
<br />Susincs rnd Pn)rc\irr Culc) A y Cny or Counry \rhich lc+tcs n nsnir r. tdtr{rucr' .1r". impr'vc. dcnnrlish ^r rqmir unv
<br />(tu.r!rc. prntr ro ris rssurncc, rh. tcqun srhc lPPliclnr fix su.h lrflnilt' Illl I \i8Nd sr .!rcnr thir h.or shc G li"tr{d pu^uanr
<br />b thc pnivi\n,ns.frh. conltrctn'\ Li.ciscd tiw (chaPrcr q. connlEncin3 *irh s"rion Tlxxr ol Divtion '1 of lh' Rren'\\ rnd
<br />l'n,lc$i.ns Codcl or thar tr or shc iscrcnPr rhcrclio'nrnd rhc h.\t lq rhc lrs.d.xcnDrion AyviolirionofS'don 70'll 5 i'yaiy
<br />,mlicnr for r rcrmir srhjt.rsrh. aprlicrnro scirillcnrllyolnor trcrh$ lrrc hrfrlrcd rlolli,s(3500)
<br />-1,
<br />a owncr ol rhc l(,|Eriy. {n nry cm!tD!c\ $irh wasc\ r\ rhcn qr! co'nF.\dn,r' will&,lh( sork dxl rh. \rturm s nor
<br />innayld nr.rIcrcd ror \rlt rsc ?(t1-1. tlu\intl\rid PmlcssionsCnd. lhtc. rncroisL.iccn\ctrqdocsnor,tpltlounowncror
<br />rhc,mpcny sho hui r or itnpr)vcs rltk,n. ({ !tx) d$\ luch $lrk hnnscll'or hcrr.lf.r rhrough his or h'r own coul(rycc\'
<br />povirrrrrnar.uct' imp( dtnrs t nn i' ctrdcd .r ofltti ht {rlc ll. k'*owr rhu lrtilJi'rg or inprovctrd k $ld sirht ot' rnr
<br />;ton&k .tuOwn( Blildrsillhrrc rhcllrlcn.rfldvingtr' |rcorshcdid tror tniklorinDrovc rlE lm|Elv ror rhc luqxM or
<br />l.rsowmroilhcnn)p-dy,rflrcr.lu\ilcly.ont rins wirh li.cn{d .rnri.n)r x, c.nnru.r rlE l&jccr (sN' ?Or4 BFinc\
<br />Rl Pnrlsrirn Codc: 1 ic Conra.ktr's Lic.n\. 1 r* J(ts nor qrDly r. !n os ( o f [o|In v *h{r buikl\ or impolcs rh'r"n'
<br />and sho .onrn Nr,,suthptr+dsuirh (in rucro( g licrn*d Pnu'nl l,
<br />'
<br />llt Cofi rois l,iccn* ta* r.
<br />l,nrcre!,fl !ndc, stcr
<br />-/-l,ut 't.rukhed
<br />I hcEhy sfiirm undcr Fn.l'yol
<br />WORI(EIS' COMPENS,{T!ON
<br />DECLIAAIION
<br />rh. followin3 dccldlrbns
<br />I hrve and * ill roi ain n Ccniticarc of C.n*nr lo Scl nsur,r workEl coryr.n{rion, N l,rovidcd fo. by Sslion l7O0 ofrn
<br />litx, Codc. for thc l,crformtr..c ol th. wortr ,or whi.h rhc F.mn is i$!cd
<br />Ihsvcandwill'n imdil workcls corDcnsrlion i.suroncc, !\ iequncd bv Scdt'n]7m.irhc Lrhor Oodc. for rhc pcrfornun'c ol
<br />thc wort t$ *hichrhi$rcrmil ii nslcd. MyworkcrJ compcniari.n incu.r.cc c!tricr ,nd ,,olicv nunrbc! @:
<br />PolicrNumher: ExI,iEr
<br />-l
<br />anify rh'l indc FrformBc ofth. w.rt fot rhth rhis Frfrit is isslcd. I .hrll ml cryhv lov p.Mn in onv ruftr
<br />s $ b tE oB $bj.ci lo rlE wortsl odpenrdaon Lws ofcrlifodi& ..d !!te lhd ir I shotld hdoft rublrr io thc
<br />wolt6 on{Ensrhn prcvisions of scdion l7(lo of lhc Lltor Code l slull. fonhwnh Nfiplv wilh lhos p&visiof,s..
<br />WARNINC: Flilurc ro src wtrlcB' @mp.ns,lion ovcEEc h unhwtut. ond rhall subjet 4 o.lloFr lo simiMl lEMI'ts lnd
<br />civil fincs !I, ro oic hundrcd lhou\u.d do IO0.0OO). nr addiriotr !o lhc cosr uf.omPcNstion, drmBcs os Providcd for fic
<br />S.rrlrr rl)ra.l rh.l rlrtr (i)(lr. i!rr. ]rl
<br />D .:-
<br />DI T,.!tsJTQN
<br />I hcEb)r ird undcr r.n,llyoiFrjury rhd I0m und;r pvisionotCiopr( 9 (.ommh-'in8 wnh sdion 7000) of Divhion 3
<br />of rhc Businc$uod PmfcasionsCodc. and nyli..ne n in tull iorcc rxl cfi.cl
<br />CONSTRIICII(IN I FNDIN(: A(iF\CY
<br />I hc&by ,Ifrrn uldcr pcnalry of l).dury rhd rfioc ! a snerudion tidi.g ag.my for lhc poft,'mNc of thc vork for whth lhis p'mir i'
<br />isslcd (Scc :1097, Civ C.).
<br />trn,l.r'i Adrlrc!
<br />APIII ICAN'I DFCLARA'I'I( IN
<br />I holhy linnudcr pctrrlry olpcrjuryotrc.ilhc lolnrwi'i8 dc.l,nrions:
<br />Dcnmlirio! Pcrmih A\lt{os Noliicrridr Ijudctrl Rc[ulnrionr (Tirlc 40. Pnn6r
<br />Rcquiredtx(crofNorifi( inr
<br />il.r
<br />74,cnv
<br />I 7-/I
<br />ID/SIG.
<br />Gas Pipino
<br />Rouqh Water Heater
<br />lz-r\
<br />'l/ntt,IY
<br />,--\,,-.?thrlL /)V1<aa,t
<br />Au+A
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